System for seeking for an optimal configuration of a bi-, tri- or multi-ventricular cardiac resynchronization implanted device

ABSTRACT

An apparatus and a system for seeking for an optimal configuration of a bi-, tri- or multi-ventricular cardiac resynchronization implantable medical device. This system includes ventricular pacing, a signal representative of an endocardial acceleration (EA) of a patient&#39;s heart, and isolating and pre-processing the EA signal to obtain an EA1 component and an EA2 component. The effectiveness of the current pacing configuration is evaluated by one or more composite indexes that combine at least two of the following parameters: peak-to-peak amplitude (PEA1) of the EA1 component; time occurrence (TstEA1) of the beginning of the EA1 component; time interval (LargEA1) between the beginning of the EA1 component and the moment of the energy peak of the EA1 component; and duration of systole (Syst), represented by the time interval between the beginning (TstEA1) of the EA1 component and the beginning (TstEA2) of the EA2 component.

FIELD OF THE INVENTION

The present invention relates to “active implantable medical devices” as defined by the 20 Jun. 1990 Directive 90/385/EEC of the Council of the European Communities, and more particularly to those devices that continuously monitor a patient's heart rhythm and deliver to the heart, if necessary, electrical pulses for joint and permanent stimulation of the left and the right ventricles, so as to resynchronize them, said technique being known as Cardiac Resynchronization Therapy (“CRT”) or Bi-Ventricular Pacing (“BVP”).

BACKGROUND

Cardiac resynchronization is known whereby a patient is implanted with a device equipped with electrodes to stimulate various sites in both ventricles (often called a CRT device or CRT pacemaker). The CRT device typically applies between the respective moments of stimulation of the left and right ventricles a delay that is called an “interventricular delay” (VVD) which VVD is adjusted to resynchronize the contraction of both ventricles to optimize the patient's hemodynamic status.

A CRT pacemaker is for example disclosed in EP 1108446 A1 and its counterpart U.S. Pat. No. 6,556,866 (both assigned to Sorin CRM S.A.S., previously known as ELA Medical), which describes a CRT device for applying between the two ventricular pacing sites a variable VVD, adjusted to resynchronize the contractions of the ventricles with a fine optimization of the patient's hemodynamic status. The VVD may be zero (meaning that the left and right ventricles are stimulated essentially simultaneously), positive (meaning that the left ventricle is stimulated after the right ventricle) or negative (meaning that the right ventricle is stimulated after the left ventricle).

Clinical studies have often observed a dramatic improvement in results for patients diagnosed with heart failure that is not improved by conventional therapy, because the parameters of the CRT therapy have been precisely adjusted according to the patient and to the nature of the patient's disorder.

But the implementation of CRT devices remains a very delicate intervention for the practitioner, because of the many choices that must be made. First, it must be determined for each of the leads the best stimulation site. The physical locations of the pacing electrodes for each lead relative to the myocardial tissue are called “pacing sites”; generally, these pacing sites can only be selected at implantation, by appropriate positioning of the electrodes. It is important to verify the effectiveness of the selected pacing sites, due to the possible influence of long-term efficacy of the resynchronization therapy. In some cases, the CRT device has several multi-site electrodes placed in the same cavity, and a change of pacing site(s) for delivering stimulation pulses in this cavity is possible by internal switching of the device.

In any case, during the intervention, the practitioner tests several possible pacing sites by successive repositioning of the lead to find the one that he believes is the most appropriate.

Another aspect of the development of these CRT devices is the increasing number of electrodes, especially for “multisite” devices that allow selecting the pacing sites used for the delivery of stimulation pulses and detection of myocardial potentials (e.g., from spontaneous cardiac events) and optimizing the operation of the CRT device.

The increasing number of electrodes can also result from the presence at the same level of the lead of several sectorial electrodes (electrodes specifically directed in a radial direction relative to the lead, at the pacing site), with the possibility to select one or the other of these sectorial electrodes to optimize the delivery of pulses to the selected pacing site. This is particularly true for leads implanted in the coronary venous system, for indirect stimulation of a left cavity: with several sectorial electrodes, it is possible to select one that is turned towards the epicardium wall facing the cavity in contact with this wall.

Second, with the development of implantable medical devices for stimulation of more than two ventricular sites, it is necessary to determine whether this *** “tri-ventricular” or “multi-ventricular” mode of stimulation is or is not preferable to a conventional “bi-ventricular” pacing mode.

Thus, the practitioner may be faced with a choice between a standard mode of bi-ventricular pacing (right and left ventricles), a tri-ventricular pacing mode (simultaneous stimulation by three electrodes, with an additional electrode in the right or left cavity), or even multi-ventricular (with multi-electrode leads for which multiple electrodes of the same lead are used concurrently). By appropriate switching, the practitioner can choose the most appropriate stimulation mode, but the number of possible configurations increases very rapidly with the increase of the electrodes, making the task all the more difficult for the practitioner, faced with a choice between a large number of different configurations.

Third, the device should be set properly, including the atrioventricular delay (AVD) and interventricular delay (VVD).

The many opportunities arising from these various choices are referred to as “pacing configurations.”

Indeed, it appears that today, even with full implementation of procedures, there are approximately 30% of patients who do not respond to CRT therapy, with serious consequences that can be imagined in terms of quality of life, hospitalizations for heart failure and reduced life expectancy.

Most studies now focus on methods to treat this refractory patient population by testing new stimulation configurations, and seeking to optimize the stimulation setting, during the implantation as well as on an ongoing basis, by periodic reassessments.

There is thus a real need for a technique to evaluate, according to a simple, rapid, automated and precise method, the impact of the choice of the stimulation sites and of the parameters of CRT therapy, especially the AVD and VVD, so as to optimize the patient's hemodynamic status.

The reference technique for the adjustment of CRT stimulation parameters is an assessment by echocardiography with estimation of the characteristic delays of the systole, in particular the delay of opening of the aortic valve. This procedure, which must be implemented in hospitals and by qualified personnel, is time consuming and expensive and can not be applied as often as would be useful or necessary. In addition, it is not easy to perform ultrasound measurements during the implantation procedure, as the sterile field does not allow easy access to the patient's chest with the ultrasound probe.

Other techniques have been proposed to evaluate the effectiveness of the choice of stimulation pacing sites and of the setting of CRT therapy parameters. Thus, EP 1736203 A1 and its US counterpart U.S. Pat. No. 7,664,547 (both assigned to Sorin CRM S.A.S, previously known as ELA Medical) describe a CRT device that uses for this purpose the parameters related to endocardial acceleration (hereinafter “EA”) to determine an optimal pacing configuration, at the time of implantation or thereafter.

Indeed, it may be necessary to reassess these choices later, after the initial implantation, and eventually readjust the settings. The benefits provided by CRT therapy can ultimately lead to change the initial configuration and setup of the stimulation.

Indeed, several clinical studies have shown that endocardial acceleration is a parameter that accurately and in real-time reflects phenomena related to the movements of the heart chamber, and can therefore provide comprehensive information on the mechanical heart, both in the case of normal operation and in the case of a deficient operation. Endocardial acceleration is for example measured by an accelerometer integrated into an endocardial lead, as described for example in EP 0515319 A1 and its US counterpart U.S. Pat. No. 5,304,208 (both assigned to Sorin Biomedica Cardio SpA).

WO 2006/049538 A1 (St. Jude Medical AB) describes a known technique to evaluate a physiological parameter that reflects the hemodynamic performance of the heart for a given stimulation configuration, from various sensors (pressure, acceleration, acoustic) placed on one or more leads, some of them being possibly repositioned; thus the signal delivered by these sensors depends on the current position of the lead and cannot be a reliable reference. However, the proposed technique has a number of drawbacks, including the fact that the optimization is based on the analysis of a single physiological parameter (e.g., cardiac output, stroke volume). However, some patients may be more or less sensitive to either of these parameters, which is not always the same from one patient to another because of the specific response of the patient, his pathology and the evolution of it. Further, the analyzed parameter is not necessarily the most relevant relatively to the changes in the stimulation configuration.

OBJECTS AND SUMMARY

It is, therefore, an object of the present invention to propose a system or apparatus that can help the practitioner find the pacing configuration that is the most appropriate, especially to enable the practitioner to evaluate the effectiveness of modifications to pacing configurations due to repositioning of lead and, where appropriate, selections of additional leads (bi-ventricular, tri-ventricular or multi-ventricular pacing) or switching of electrodes in the case of a multi-electrode lead.

It is another object of the present invention to provide a technique for evaluating the pacing configuration with an increased sensitivity and specificity compared to what has been proposed to date, including the EP 1736203 A1 cited above, particularly with respect to changes of position of the pacing electrodes.

It is another object of the present invention to define indexes of cardiac hemodynamic performance of the patient, to optimize the positioning of the leads and the choice of configurations of the CRT pacemaker during the implantation procedure, and the possible reprogramming of any parameter after the CRT device implantation.

Another object of the present invention is to provide complete equipment, made available to the implanting practitioner, which is specifically adapted to the selection of stimulation pacing sites during the process of implantation of the leads and of a bi-ventricular, tri-ventricular or multi-ventricular device.

To this end, the present invention is broadly directed to a system for seeking an optimal pacing configuration for an active medical device (implantable cardiac prosthesis or external device used temporarily) implementing CRT by bi-, tri- or multi-ventricular pacing, this system including, as taught by and disclosed in EP1736203 A1 cited above, to which one skilled in the art is referred:

-   -   means for ventricular pacing, able to deliver stimulation pacing         pulses to be applied to electrodes located respectively at least         at one right ventricular pacing site and at least at one left         ventricular pacing site according to a predetermined pacing         configuration that is current and modifiable;     -   an acceleration sensor for delivering an endocardial         acceleration (EA) signal representative of cyclical contractions         and relaxations of the heart, and     -   Means for isolating and preprocessing in the EA signal during a         given cardiac cycle between two successive ventricular         events: (i) an EA1 component corresponding to the first peak of         endocardial acceleration associated with the isovolumetric         ventricular contraction, and (ii) an EA2 component corresponding         to the second peak of endocardial acceleration associated with         the isovolumetric ventricular relaxation.

It is another aspect of the present invention to assess the efficiency of stimulation based on a “performance index” compiled from parameters from a signal delivered by an endocardial acceleration sensor, including: the amplitude of the first endocardial acceleration peak, the duration of this peak, and the duration of systole (i.e., the interval between the first and second peaks of endocardial acceleration).

Preferably, a system in accordance with the present invention further includes means for evaluating the effectiveness of the current pacing configuration, including:

-   -   Means for extracting at least two parameters from the isolated         and pre-processed EA1 and EA2 components:         -   Means for combining said at least two parameters in a             composite index representative of the effectiveness of that             current pacing configuration;         -   Means for determining a plurality of values of said             composite index for a corresponding plurality of different             pacing configurations, and         -   Means for determining a preferred pacing configuration from             said plurality of values of said composite index by             searching for an optimum of that composite index.

In a preferred embodiment, said at least two parameters characteristic of the EA1 and EA2 components are parameters selected from among the group consisting of:

-   -   PEA1=value of the peak-to-peak EA1 component;     -   TstEA1=duration of occurrence of the beginning of the EA1         component represented by the time interval between i) a temporal         marker of the beginning of the cardiac cycle and ii) the         crossing of an energy envelope threshold of the EA1 component;     -   LargEA1=time interval between i) said crossing of the energy         envelope threshold, and ii) the instant of the peak of said         energy envelope of the EA1 component; and     -   Syst=duration of systole, represented by the time interval         between the beginning of the EA1 component and the beginning of         the EA2 component,

In one embodiment, the composite index is an index selected from among the group consisting of:

-   -   Ind1=(TstEA1×LargEA1)/(Syst×PEA1) ;     -   Ind2=(TstEA1×LargEA1)/[(Syst−LargEA1)×PEA1];     -   Ind3=(TstEA1×LargEA1)/(Syst); and/or     -   Ind4=(TstEA1)/(PEA1),         said optimum being a minimum of the indexes.

The system advantageously comprises an atrial lead carrying the endocardial acceleration sensor, and left and right ventricular leads with their distal electrode respectively defining the pacing site(s) for right and left ventricular pacing according to the current pacing configuration. It may also include an additional, right or left, ventricular lead carrying at its distal end electrodes for definition of at least one additional pacing site for ventricular pacing, defining the current pacing configuration in combination with the right and left ventricular pacing site(s).

Another embodiment of the present invention is directed to a system including:

-   -   An implantable active medical device capable of delivering CRT         by bi-, tri- or multi-ventricular stimulation;     -   An atrial lead carrying an endocardial acceleration sensor;     -   Right and left ventricular leads respectively carrying distal         electrodes for definition of the right and left ventricular         pacing sites according to a current pacing configuration;     -   Optionally an additional, right or left, ventricular lead         carrying at its distal end electrodes for definition of at least         one additional ventricular pacing site, defining the current         pacing configuration in combination with the right and left         ventricular pacing site(s);     -   An external device for providing cardiac detection/stimulation         for a patient;     -   An interface unit comprising means for processing an EA signal,         provided by said EA sensor, and means for coupling the external         equipment to the atrial and ventricular leads; and     -   External programmer means, coupled to the interface housing for         reception of the processed EA signal, including the means for         evaluating the effectiveness of the pacing configuration.

DRAWINGS

Further features, characteristics and advantages of the present invention will become apparent to a person of ordinary skill in the art from the following detailed description of preferred embodiments of the present invention, made with reference to the drawings annexed, in which like reference characters refer to like elements, and in which:

FIG. 1 is a series of three timing diagrams illustrating various signals characterizing the cardiac activity during a given cycle;

FIG. 2 illustrates, in more detail, the shape of the endocardial acceleration signal during a given cardiac cycle, with the various parameters used for the implementation of the invention;

FIG. 3 schematically illustrates the various elements of a preferred embodiment of the present invention in the form of functional block diagrams, of the equipment available to the practitioner at the time of implantation for the selection of the pacing sites of the invention;

FIG. 4 illustrates a diagram displayed by the interface of FIG. 3 for selection of the pacing sites;

FIG. 5 is a flow chart describing the various stages of a preferred method of implementing the elements of the present invention; and

FIG. 6 is a flow chart describing the various stages of the long-term patient's monitoring by analysis of the evolution of one or more of the indexes calculated according to a preferred embodiment of the present invention.

DETAILED DESCRIPTION

With reference to the drawing FIGS. 1-6, a preferred embodiment of an apparatus according to the present invention will now be described.

The present invention may particularly be applied to active implantable medical devices such as those of the Paradym CRT device family produced and marketed by Sorin CRM, Clamart France, formerly known as ELA Medical, Montrouge, France. These devices include programmable microprocessor circuitry to receive, format, and process electrical signals collected (detected) by electrodes implanted in a patient, and deliver stimulation pulses to these electrodes. It is possible to transmit by telemetry software that will be stored in a memory of the implantable devices and executed to implement the functions of the invention that will be described herein. The adaptation of these devices to implement the functions and features of the present invention is believed to be within the abilities of a person of ordinary skill in the art, and therefore will not be described in detail.

The technique of the present invention is based on the analysis of endocardial acceleration (hereinafter “EA”), which is a parameter that accurately and in real time reflects the phenomena contributing to the mechanical operation of the myocardium and may be measured by an accelerometer coupled to the heart muscle, as described for example in EP 0515319 A1 (and its counterpart: U.S. Pat. No. 5,304,208) (Sorin Biomedica Cardio SpA). This document teaches a method to collect an EA signal through an endocardial lead equipped with a distal stimulation electrode implanted in the atrium or ventricle and integrating a microaccelerometer to measure endocardial acceleration.

Note however that, although in the present description it is referred mainly to the analysis of an EA signal delivered by a sensor placed on an endocardial lead, the invention is also applicable to an analysis conducted from an EA signal delivered by other types of implanted sensors, such as a myocardium wall motion sensor, an epicardial sensor or an accelerometer placed in the case of an implant. The invention is also applicable to the analysis of a noninvasively collected external EA signal, e.g., from a sensor attached to the patient's chest at the sternum.

FIG. 1 shows the different signals characterizing the activity of a patient's heart during a cardiac cycle, with: the profile of intracardiac pressures (P_(A), P_(VG) and P_(OG)), a record of surface electrocardiogram (ECG), and the variations of the endocardiac acceleration (EA) signal. The characteristic P_(A) shows the variations in the aortic pressure, P_(VG) in the left ventricular pressure and P_(OG) in the left atrium pressure. Points A to E correspond to the different following phases: A contraction of the left atrium, B closure of the mitral valve, C opening of the aortic valve, D closure of the aortic valve, E opening of the mitral valve. The ECG signal has successively the P wave corresponding to the depolarization of the atria, the QRS complex corresponding to the depolarization of the ventricles, and the T wave corresponding to the ventricular repolarization.

The EA signal collected during a given cardiac cycle forms two main components, corresponding to the two major heart sounds (S1 and S2 sounds of phonocardiogram) that can be recognized in each cardiac cycle:

-   -   the EA1 component, starting after the QRS complex is caused by a         combination of the closure of the atrioventricular valves, the         opening of the semilunar valves and the contraction of the left         ventricle. The amplitude variations of this EA1 component are         closely related to the changes in pressure in the ventricle (the         maximum peak to peak amplitude being specifically correlated         with the positive maximum of dP/dt pressure variation in the         left ventricle) and thus can provide a parameter representative         of the myocardium contractility, which is itself linked to the         level of activity of the sympathetic system; and     -   the EA2 component occurs during the phase of isovolumetric         ventricular relaxation. It accompanies the end of ventricular         systole and is mainly produced by the closure of the aortic and         pulmonary valves.

For one implementation of the present invention, it is first necessary to extract from the EA signal, the endocardial acceleration and more specifically the two components EA1 and EA2, characteristics correlated with time intervals of the systole and to other myocardium hemodynamic performance indexes, by specific processing of this EA signal.

The preliminary processing of the EA components preferably involves, first, to individualize the successive cardiac cycles in the EA signal that is continuously collected, identifying markers of the beginning of the cycle to separate these cycles and isolate a series of EA sub-signals bounded in time, each corresponding to a period of one cardiac cycle.

In the case of an endocardial EA signal, the time markers of the beginning of the cycle may be provided by the implant itself or by an external device during implantation, which according to the mode stores the timings of V pacing, or the timings of R-wave detection. The temporal marker of the beginning of the cycle, which is the origin of time, is designated “O”.

The next step is to isolate the EA1 and EA2 components in each sub-signal bounded in time corresponding to one cardiac cycle. Each of these EA1 and EA2 components are represented by a set of successive values describing the continuous variation of the EA signal in a given time window extending around the peak of the EA signal (PEA1 peak or PEA2 peak), for a fraction of the duration of a cardiac cycle. Specifically, each component consists of a subset of the EA signal samples obtained after digitization of this signal over the duration of the cardiac cycle.

Each of these components represents a fraction of the EA signal on the duration of a cardiac cycle, each cardiac cycle comprising a plurality of different components that occur in succession, including the first two components EA1 and EA2, which are followed by secondary components known in the art as EA3 and EA4.

Preferably, the EA1 and EA2 components of the signal EA are determined with an averaging over several cycles, typically three to five cycles, using a technique such as that described in EP 2092885 A1 (and its counterpart: US Patent Publication No. 2009/0209875) (both assigned to Sorin CRM S.A.S., previously known as ELA Medical), a technique that allows including the elimination of the cycle to cycle variations by a time readjustment of the successive components before averaging.

Essentially, this technique is to perform a preprocessing of the EA signal continuously collected, with:

-   -   Division of the EA signal into sub-signals each corresponding to         the duration of one cardiac cycle and identified by a marker of         cycle beginning to achieve this division;     -   Segmentation of each of these sub-signals in order to         individualize the EA1 and EA2 components in a given temporal         window;     -   For the current EA1 or EA2 component thus isolated on a cycle,         seeking for a cross-correlation peak with respect to the EA1 (or         EA2) components from the other collected cycles;     -   Calculation of a corresponding temporal shift; and     -   Application of the temporal shift thus calculated to the current         component, so as to align it with the others.

The analysis processing can then be performed on these successive EA1 and EA2 components, with elimination of the bias of the cycle to cycle variability as a result of the preprocessing.

In one embodiment, the present invention is based on the extraction and analysis of a number of characteristic parameters of the EA1 and EA2 components, parameters which are then combined to give composite indexes that the practitioner seeks to optimize (minimize or maximize depending on the cases), the reached optimum reflecting the best pacing configuration among all those that have been tested.

These parameters are four in number, and are illustrated in FIG. 2 which shows the variation of the EA signal during one cardiac cycle, with its two EA1 and EA2 components:

-   -   The peak-to-peak component EA1, designated PEA1;     -   The timing of the beginning of the EA1 component, denoted         TstEA1, which is a period counted from the time origin O in FIG.         2;     -   An indicator of the duration of the EA1 component, designated         LargEA1, which is the time interval between the instant TstEA1         from the instant t_(maxEA1energy) of the energy peak of the EA1         component; and     -   The duration of systole, designated Syst, corresponding to the         time interval between TstEA1, which marks the beginning of the         EA1 component, and TstEA2, which marks the beginning of the EA2         component.

The timings TstEA1 and TstEA2 of start of the EA1 and EA2 components can be obtained by thresholding an envelope of energy obtained by squaring the value of the signal samples (envelope shown in dashed lines in FIG. 2), then applying a smoothing window of 100 ms, for example. The timings TstEA1 and TstEA2 correspond to a threshold that can be for example 10% of the maximum energy of the considered window corresponding to the one and the other of two EA1 and EA2 components.

The respective timings of occurrence of the maximum energy of the EA1 and EA2 components, denoted t_(maxEA1energy) and t_(maxEA2energy), are used to calculate in particular the LargEA1=t_(maxEA1energy)−TstEA1.

This method for determining characteristic instants of the EA1 and EA2 components is described as well as others in EP 2092885 A1 and its counterpart US Patent Publication No. 2009/0209875 cited above, which can be referred for more details and are incorporated herein by reference in their entirety.

The above parameters are chosen for the following reasons:

-   -   the PEA1 amplitude is associated with the cardiac contractility         (clinical studies have shown a strong correlation with the         maximum LVdP/dT). Effective stimulation for an optimal position         of the pacing electrode, has the effect of maximizing this         parameter.     -   The timing of occurrence of the beginning of the EA1 component         TstEA1 is associated with the phase of isovolumetric contraction         of the cardiac cycle, particularly at the instant of opening of         the aortic valve, timing also known as “Left Pre-Ejection         Interval”, LPEI. Clinical studies suggest that minimization of         this parameter reflects an improvement in ventricular         resynchronization and hemodynamic performance. It can also be         found that this parameter is also very sensitive to changes in         position of the electrodes of the lead.     -   The duration LargEA1 is a good indicator of the         resynchronization. Reduced values should be sought for the         duration of this value. It was also found that this parameter is         much more sensitive to changes in the positions of the         electrodes, in particular, the full length of the EA1 component         (time interval between the beginning and the end of the EA1         component). It is also more reliable than a technique of using         the instant of the end of the EA component by detecting it by         thresholding and averaging over several cycles: a relatively         high variability is then found compared to the moment the peak         is reached.     -   The duration of systole Syst is associated with the time between         the closure of the mitral valve and that of the aortic valve.         This parameter gives a good indication of the performance of the         ejection phase. This parameter is also very sensitive to changes         in position of the electrodes.

In other words, the above four parameters have a particularly high sensitivity and accuracy in response to changes in pacing configurations, which very effectively guides the practitioner in the selection and adjustment of the pacing sites.

These parameters are also sensitive to the pacemaker settings (including AVD and VVD delays), and may be used for initial adjustment or later readjustment.

However, the optimization of one of the four above parameters is not always sufficient to determine with certainty the best pacing configuration and the best settings of the device. The use of a single parameter in fact leads to an excessive number of incorrect determinations, which is why the present invention proposes to combine a plurality of these parameters (at least two) in one or more indexes called “composite indexes” to reliably determine the best choice of pacing configuration.

The following composite indexes were chosen because they are all very sensitive to changes in position of the pacing sites:

-   -   Ind1=(TstEA1×LargEA1)/(Syst×PEA1): This index combines the         various characteristic durations of the cardiac cycle and the         parameters reflecting contractility, and has the highest         sensitivity to changes in the position of the pacing sites and         the best correlation with the clinical references;     -   Ind2=(TstEA1×LargEA1)/[(Syst−LargEA1)×PEA1]: This index is very         similar to the previous one, but the difference Syst−LargEA1         enables more stability in the factor related to the duration of         systole;     -   Ind3=(TstEA1×LargEA1)/(Syst): This index is derived from the         first one, without contribution of contractility and is more         suitable for applications in which optimization is strictly         related to the timings of the cardiac cycle and is not or is         little dependent of contractility;     -   Ind4=(TstEA1)/(PEA1): This index is a subsidiary index and         reflects cardiac performance when optimization is only those of         the phase of ventricular contraction. It can particularly be         used if the closure of the aortic valve is difficult to detect         (that is, when the EA2 component is hardly visible), leading to         an uncertain determination of the duration of systole Syst,         because of an unreliable signal related to the relaxation phase         of the cardiac cycle.

For all these indexes, the optimum to seek is the minimum.

The composite indexes above have proved to be very effective in clinical studies, and adapted to many different hemodynamic conditions of patients, for various pathologies.

This list is not exhaustive, and persons having ordinary skill in the art would understand that other combinations of the parameters listed above can be used in other situations or particular pathologies.

A preferred method to achieve, in practice, an optimization in accordance with the present invention during the implantation phase, with reference to FIGS. 3-5, will now be described.

FIG. 3 schematically shows the facility used to optimize the position of the pacing sites and of the programmed parameter configurations. The system includes a CRT pacemaker and/or resynchronizer implantable medical device 10, provided with a plurality of leads implanted in the heart with a right atrial lead RA, referenced 12, equipped at its distal end with an EA sensor, e.g., an accelerometer for delivering an EA signal 14. Note that the EA sensor is placed on an atrial lead, which is therefore another lead than those to be displaced to find an optimal pacing configuration. In other words, the lead on which the EA sensor is placed is not involved in the definition of the “pacing configuration” in the sense described above.

The device is also connected to right ventricular RV and left ventricular LV leads, referenced 16, 18, and possibly to an additional ventricular lead V+, referenced 20, which can be used to improve the ventricular performances, especially if pacing by the RV and LV lead does not provide sufficient improvement in hemodynamics.

These leads are directly connected to the generator 10 and temporarily, via sterile cables, to an interface unit 22 for seeking of the optimal pacing configuration.

The ventricular lead may also be, as shown in 20′ on the variation in the lower right heart scheme, a ventricular right or left “multi-electrode” lead. The EP 1938861 A1 (and counterpart: U.S. Patent Publication No. 2008/0177343) and EP 2082684 A1 (and counterpart: US Patent Publication No. 2009/0192572) (both on behalf of Sorin CRM S.A.S., previously known as ELA Medical) describe such a lead having a plurality of electrodes near its distal end, for example, ten electrodes, associated with a chip, hermetically encapsulated in the vicinity of the electrodes in a rigid ring, providing the multiplexing/demultiplexing of the electrodes with a common bus having two insulated conductors extending along the entire length of the lead to the proximal connector for coupling with the generator, the latter being equipped with a counterpart circuit for demultiplexing/multiplexing.

The interface housing 22 includes a proper interface 24 for receiving signals from the electrodes RA, RV, LV and V+, or delivery of pacing pulses on these same conductors. A stage 26 is used to filter and amplify the various detected depolarization signals and the EA signal. A multiplexer 28 also selectively ensures switching of the various conductors with a Pacemaker System Analyzer (“PSA”) or temporary pacing system 30 for external stimulation, possibly included in the interface unit 22, designed to continuously ensure functions of detection and generation of stimulation pulses during testing of the different configurations, in relay of the implanted generator 10 or before connecting it to the leads 12, 16, 18 and 20.

The system also includes a programmer 40 or another computer system, comprising a software module for the acquisition and processing of EA and cardiac depolarization signals, particularly for calculating one or more of the composite indexes Ind1 to Ind4, in accordance with the present invention. This programmer 40 includes a processing unit 42, a measurement unit 44 and a storage memory 46. It can possibly be expected to include a keyboard 48 or other conventional means of data entry.

Finally, a display 50 allows the practitioner to present the various options available to him to define the various pacing configurations. The display can take the form shown in FIG. 4, with a schematic representation of the different regions of the heart identifying the key targets:

-   -   For the right atrium RA: atrial appendage AA, lateral wall LW         and atrial septum AS;     -   For the right ventricle RV: output flow track region OFT, low         septum LS, medium and high septum, MS and HS, and bottom APEX;     -   For the coronary system CS (by which the left ventricle is         stimulated): great cardiac vein GCV, lateral vein LV,         posterolateral vein PLV, posterior vein PV and middle cardiac         vein MCV.

FIG. 5 shows an example of a preferred method in accordance with the present invention for the selection of the best pacing configuration at the time of implantation. After the various initializations (step 100), the practitioner checks the configurations to be tested (step 102). The reference condition which is then used for the various comparisons can be that corresponding to the particular patient's spontaneous rhythm in order to allow the spontaneous rhythm be expressed (step 104). For safety, the external stimulator (PSA) is normally disconnected from the lead; it is connected only for the later steps of testing the various pacing configurations.

The detection thresholds for synchronization of the sensor signals are also determined during this initial phase (step 106).

The external generator (PSA) is then connected, stimulation is applied and various checks are performed, including the stability of the rhythm (step 108).

An initial configuration is then tested (step 110), the EA signal processing producing (block 112) the sought composite indexes Ind1, Ind2, Ind3 and/or Ind4 (it should be understood however, that obtaining two of these indexes is usually sufficient).

Other pacing configurations are then tested with different electrode switching (step 114). Note that the setting of the AVD and VVD is generally not changed at this step (rather they are changed at a later step of possible optimization after site selection and monitoring of the patient). It may in particular be programmed with a short AVD selected in the range from 80 to 100 ms, and a VVD equal to zero.

The corresponding indexes are evaluated (block 116) and compared with the reference indexes, to give an overall result (step 118).

The practitioner can then change the location of the leads or reposition them (block 120) and repeat the process described above (back to step 100), to again give new results in step 118.

The successive results obtained are compared in order to determine the pacing configuration providing the optimal efficiency. For example, the practitioner can test various configurations. The first set of test configurations is a “standard” set including:

-   -   Spontaneous rhythm (as reference);     -   Stimulation of the right ventricle RV alone (for purposes of         diagnosis or as a reference configuration);     -   Stimulation of the left ventricle only;     -   Conventional bi-ventricular pacing (which can also be chosen as         the reference configuration), with concomitant stimulation of         both right and left ventricles RV-LV.

The diagnosis is used to evaluate the sensitivity of the indexes in the worst conditions of stimulation, for a patient with heart failure; it is not, however, to consider such stimulation as a possible programmable pacing configuration.

Then, all possible configurations involving repositioning the lead or the addition of an additional lead V+ are tested. The repositioning of the RV and LV leads involves repeating the test for basic configurations RV only, LV only, and RV-LV. Adding an additional lead V+ to stimulate the left or right ventricle involves testing all possible pacing combinations:

-   -   Bi-ventricular (concomitant stimulation LV-V+ or RV-V+),     -   Tri-ventricular pacing (concomitant stimulation V+, RV and LV),     -   Multi-ventricular pacing (concomitant stimulation on several         electrodes of a multi-electrode lead, and on RV and LV).

The configuration in spontaneous rhythm is always reassessed at the beginning of each series of tests, and indexes are compared with those obtained the first time (reference configuration). If a substantial variation of the index in the spontaneous condition is established, a warning is displayed, and the practitioner should check the patient's condition: indeed, a change in the index should not normally occur, otherwise it is a symptom of deterioration of the patient, to be taken into account immediately.

The practitioner can for example test the following three sets of configurations shown in the following table:

Configu- Implanted Brought configurations to be tested rations lead changes (new or modified) n° 1 RA, RV, LV — spontaneous, LV only, BiV n° 2 RA, RV, LV RV Spontaneous, BiV repositioning n° 3 RA, RV, V+, LV V+ added spontaneous, BiV+, TriV

Of all the tested configurations, the one that is selected is the one that produces the optimal of the composite index(s) (the minimum value with the indexes Ind1 to Ind4 exemplified above).

Later, after the stimulation pacing sites have been selected, a comparable analysis algorithm can be implemented to test configurations differing in the settings of the AVD and/or the VVD to maximize the values of these parameters. It may be the same after implantation in the patient follow-up, in order to assess the impact of a change in the pacing configuration and/or in the setting of the AVD and VVD.

It is thus possible to calculate the indexes for each pair of values {AVD, VVD}, then to choose the pair that is associated with the highest index value. The analysis can be done by trying to optimize the composite indexes Ind1, Ind2, Ind3 and/or Ind4 described above (the optimization typically is on two of these indexes).

It is also possible to use the indexes to monitor the patient's pathology in the long term, in order to assess the deleterious effects of remodeling and prevent the occurrence of an adverse event resulting from the increase of the heart failure status. It is then to assess the evolution over time of a given index to detect a deterioration in the patient's condition and send a warning to the practitioner, for example, to change the therapy (optimized pacing configuration, change in the settings of AVD and VVD, medication, etc.).

FIG. 6 outlines the various steps of such a patient follow-up on the long-term by analysis of the evolution of one or more of the indexes Ind1, Ind2, Ind3 and/or Ind4 described above. For example, for a continuous follow-up of the patient's status, the first step involves computing of indexes several times a day (3-4 times), while the patient is at rest. Next, computing of the same indexes occurs during exercise (if available). This is followed by detection of any increase/decrease of the index trend on “N” successive days (for example: N=7 days), followed by a comparison (i) to a threshold (min/max) of the variations of the index slope, (ii) of spontaneous rhythm indexes vs. ventricular pacing indexes, and (iii) of indexes at rest vs. at exercise. A test is then performed as to whether a sudden variation of the series of index values is detected. If yes, then an alert is given to the physician for patient examination; and if no then a test is performed as to whether there is significant change during time of the series of index values detected. If the result of the latter test is yes, then an alert is sent to physician for patient examination; and otherwise the routine returns to the initial step of computing of indexes several times a day (3-4 times), while the patient is at rest).

One skilled in the art will understand the present invention is not limited by, and may be practice by other than the foregoing embodiments described, which are presented for purposes of illustration and not of limitation. 

The invention claimed is:
 1. Apparatus for seeking an optimal configuration of stimulation through an active medical device (10) by resynchronization pacing of at least two ventricular pacing sites, comprising: Means for delivering pacing pulses (10, 30) to be applied to electrodes located respectively in at least one right ventricular pacing site and at least one left ventricular pacing site in a predetermined and modifiable current pacing configuration; An acceleration sensor having an output endocardial acceleration (EA) signal representative of the cyclic contractions and relaxations of a patient's heart; and Means for isolating and preprocessing in the EA signal during one cardiac cycle between two successive ventricular events: (i) an EA1 component corresponding to the first peak of endocardial acceleration associated with the isovolumetric ventricular contraction, and (ii) an EA2 component corresponding to the second peak of endocardial acceleration associated with the isovolumetric ventricular relaxation, means (40) for evaluating an effectiveness of said current pacing configuration, including: Means for extracting at least two characteristic parameters from the isolated and pre-processed EA1 and EA2 components: Means for combining said at least two characteristic parameters in a composite index representative of the effectiveness of that current pacing configuration; Means for determining a plurality of values of said composite index for a corresponding plurality of different pacing configurations; and Means for determining a preferred pacing configuration from said plurality of values of said composite index, based on finding an optimum composite index, Wherein: Said at least two characteristic parameters of the EA1 and EA2 components are parameters selected from among the group consisting of: PEA1=value of the EA1 peak-to-peak component; TstEA1=timing of occurrence of the beginning of the EA1 component, represented by a time interval between i) a time marker of the beginning of the cardiac cycle and ii) the crossing of a threshold of energy envelope of the EA1 component; LargEA1=time interval between i) said crossing of the energy envelope threshold of the EA1 component and ii) the instant of the peak of said energy envelope of the EA1 component; and Syst=duration of systole, represented by the time interval between the beginning (TstEA1) of the EA1 component and the beginning (TstEA2) of the EA2 component, Wherein said composite index is an index selected from among the group consisting of: Ind1=(TstEA1×LargEA1)/(Syst×PEA1); Ind2=(TstEA1×LargEA1)/[(Syst−LargEA1)×PEA1]; Ind3=(TstEA1×LargEA1)/(Syst) and Ind4=(TstEA1)/(PEA1), and Wherein said optimum composite index comprises a minimum of said selected index.
 2. The system of claim 1, comprising: an atrial lead (18) carrying said acceleration sensor (14); and right (16) and left (18) ventricular leads respectively carrying distal electrodes for definition of said right and left ventricular pacing site(s) in said current pacing configuration.
 3. The system of claim 2, further comprising: an additional ventricular lead (20, 20′) carrying a distal electrode for definition of at least one additional ventricular pacing site, and defining said current pacing configuration in combination with said right and left ventricular pacing site(s).
 4. The system of claim 1, wherein said means for delivering pacing pulses further comprises: a bi-, tri- or multi-ventricular pacing cardiac resynchronization implantable prosthesis (10); an atrial lead (18) carrying said acceleration sensor (14); right (16) and left (18) ventricular leads respectively carrying distal electrodes for definition of said right and left ventricular pacing site(s) according to said current pacing configuration; an external equipment (30) for detection/stimulation of a patient's heart; an interface unit (22) comprising means (26) for processing said EA signal, and means (28) for coupling the external equipment to said atrial and ventricular leads; and external programmer means (40), coupled to the interface housing to receive the processed EA signal, and including said means for assessing effectiveness of the current pacing configuration.
 5. The system of claim 4 further comprising: an additional, ventricular lead (20, 20′) carrying at least one distal electrode for definition of at least one additional ventricular pacing site, defining said current pacing configuration in combination with said right and left ventricular pacing site(s).
 6. Apparatus for seeking an optimal configuration of stimulation through an active medical device by resynchronization pacing of at least two ventricular pacing sites, comprising: Means for delivering pacing pulses to be applied to at least one right ventricular pacing site and at least one left ventricular pacing site in a predetermined and modifiable current pacing configuration; Means for receiving an endocardial acceleration (EA) signal representative of the cyclic contractions and relaxations of a patient's heart; and Means for isolating and preprocessing said EA signal during one cardiac cycle between two successive ventricular events to identify: (i) an EA1 component corresponding to the first peak of endocardial acceleration associated with the isovolumetric ventricular contraction, and (ii) an EA2 component corresponding to the second peak of endocardial acceleration associated with the isovolumetric ventricular relaxation, means for evaluating an effectiveness of said current pacing configuration, including: Means for extracting at least two characteristic parameters from the isolated and pre-processed EA1 and EA2 components: Means for combining said at least two characteristic parameters in a composite index representative of the effectiveness of that current pacing configuration; Means for determining a plurality of values of said composite index for a corresponding plurality of different pacing configurations; and Means for determining a preferred pacing configuration from said plurality of values of said composite index, based on finding an optimum composite index, Wherein: Said at least two characteristic parameters of the EA1 and EA2 components are parameters selected from among the group consisting of: PEA1=value of the EA1 peak-to-peak component; TstEA1=timing of occurrence of the beginning of the EA1 component, represented by a time interval between i) a time marker of the beginning of the cardiac cycle and ii) the crossing of a threshold of energy envelope of the EA1 component; LargEA1=time interval between i) said crossing of the energy envelope threshold of the EA1 component and ii) the instant of the peak of said energy envelope of the EA1 component; and Syst=duration of systole, represented by the time interval between the beginning (TstEA1) of the EA1 component and the beginning (TstEA2) of the EA2 component, Wherein said composite index is an index selected from among the group consisting of: Ind1=(TstEA1×LargEA1)/(Syst×PEA1); Ind2=(TstEA1×LargEA1)/[(Syst−LargEA1)×PEA1]; Ind3=(TstEA1×LargEA1)/(Syst) and Ind4=(TstEA1)/(PEA1), and Wherein said optimum composite index comprises a minimum of said selected index.
 7. The system of claim 6, comprising: an atrial lead carrying an acceleration sensor wherein said acceleration sensor produces said EA signal; and right and left ventricular leads respectively carrying distal electrodes for definition of said right and left ventricular pacing site(s) in said current pacing configuration.
 8. The system of claim 7, further comprising: an additional ventricular lead (20, 20′) carrying a distal electrode for definition of at least one additional ventricular pacing site, and defining said current pacing configuration in combination with said right and left ventricular pacing site(s).
 9. The system of claim 6, wherein said means for delivering pacing pulses further comprises: a bi-, tri- or multi-ventricular pacing cardiac resynchronization implantable prosthesis (10); an atrial lead (18) carrying an acceleration sensor, said acceleration sensor providing said EA signal; right (16) and left (18) ventricular leads respectively carrying distal electrodes for definition of said right and left ventricular pacing site(s) according to said current pacing configuration; an external equipment (30) for detection/stimulation of a patient's heart; an interface unit (22) comprising means (26) for processing said EA signal, and means (28) for coupling the external equipment to said atrial and ventricular leads; and external programmer means (40), coupled to the interface housing to receive the processed EA signal, and including said means for assessing effectiveness of the current pacing configuration.
 10. The system of claim 9 further comprising: an additional, ventricular lead (20, 20′) carrying at least one distal electrode for definition of at least one additional ventricular pacing site, defining said current pacing configuration in combination with said right and left ventricular pacing site(s). 